Central Line Troubleshooting. Beyond the Basics.


    Central Line Troubleshooting. Beyond the Basics.

    Needle, wire, nick, dilate, catheter. Sounds simple right? However, simple doesn’t always mean easy. Placing a central line on a mannequin can be much easier than the 250lb ESRD patient with peripheral vascular disease and a MAP of 50. Below are ten tips to help assist with successful line placement:


    1) Manipulate the syringe plunger prior to the procedure.

    This will lower the initial resistance of a brand new syringe and help make it easier to get blood return when you enter the vein.


    2) Don’t attach the needle to the syringe too tightly.

    The needle should be firmly attached to the syringe, but remember the goal is to be able to remove the syringe without moving the needle tip at all.


    3) Stabilize your needle!

    This is often the step that gives people the most trouble. After you get flash, you must put your entire hypothenar eminence AND all 3 other digits on the patient with a wide base, while you firmly grasp the needle hub with digits 1 and 2.


    4) Wiggle the wire within the nick.

    After you make your nick, wiggle the wire in the nick to make sure it is freely moveable throughout the length of the nick. It is possible to make a nick that is not actually contiguous with your wire tract.


    5) Wet the dilator.

    This helps create less resistance during the dilation process. You can use normal saline from the sterile syringe.


    6) Hold the dilator close to the skin.

    Doing this will give you more control over the dilator and also prevent you from dilating too deeply.


    7) Twist to dilate.

    Remember back to your days of physics class. The coefficient of kinetic friction is usually lower than the coefficient of static friction. Meaning… it’s easier to advance and retract the dilator while it’s already in motion. Twisting upon retraction of the dilator can also be very useful, especially with larger catheters, as the act of removing the catheter often has just as much dilation potential as the insertion.


    8) Dilate at the same angle as you entered the skin.

    Dilating at a different angle from the wire can kink your wire and also lead to additional tissue or vascular trauma.


    9 Keep a shallow angle with big catheters.

    The bigger the dilator and catheter (for example hemodialysis catheters), the more likely you are to penetrate the back wall of the vessel if you advance too steeply.


    10) Double Glove.

    If done under sterile conditions at the beginning of the procedure, one can take off the outer pair of bloody gloves, then secure and bandage the line in place with clean gloves. Cleaner bandage, better protection against needlesticks. Watch for slightly reduced dexterity though.



    Yang L, Mullan B. Reducing needle stick injuries in healthcare occupations: an integrative review of the literature. ISRN Nurs. 2011;2011:315432

    Scott Weingart. EMCrit Wee – Central Line MicroSkills – Dilation. EMCrit Blog. Published on August 29, 2017. Accessed on April 9th 2019. Available at [https://emcrit.org/emcrit/microskills-dilation/ ].

    Scott Weingart. EMCrit Wee – Central Line MicroSkills (Deliberate Practice). EMCrit Blog. Published on September 12, 2015. Accessed on April 9th 2019. Available at [https://emcrit.org/emcrit/central-line-micro-skills-deliberate-practice/ ].

    Triple Lumen Catheter. Digital Image. Nursejanx. April 2018, https://forum.nursejanx.com/t/what-are-the-different-ports-of-a-triple-lumen-central-venous-catheter-used-for/226

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • renal handling of water

      If you were on a tea & toast diet, how much water would you need to drink before you develop hyponatremia? I haven’t seen anyone work out the numbers before so here are my calculations. AndRead more

    • acute acidemia physiology

      As alluded to in the first post, don’t be fooled by a “normal” potassium in the setting of DKA because osmotic diuresis and H+/K+ exchange means that total body potassium is actually LOW. You all knowRead more

    • renal handling of potassium

      the first symptom of hyperkalemia is death Earlier post covered temporizing measures to counter hyperkalemia — namely, intracellular shift, increasing cardiac myocyte threshold potential. Give furosemide if the patient still urinates and consider dialysis, but then askRead more

    • bicarbonate revisited

      Previous post reviewed the safety of balanced crystalloids in hyper K. But what was up with serum bicarbonate decreasing with saline administration? This post introduces a new way of looking at the anion gap to possiblyRead more

    • hyperkalemia and balanced crystalloids

      Is it safe to give LR or plasmalyte to a hyperkalemic patient (these balanced crystalloids have 4-5 mEq/L K as opposed to 0 mEq/L K in normal saline)? Postponing the discussion of renal handling of potassium toRead more

    • hyperkalemia physiology

      You’ll likely encounter hyperkalemia on your next Resus / Cardiac shift, and you’ll instinctively treat it. But take a moment to review the fascinating physiology behind the “cocktail”! First, consider how K+ is buffered byRead more

    • Slow down your tachycardia (but not really)

      You’re sitting in resus bemoaning the departure of your most beloved attending when suddenly a patient wheels in without warning. The patient looks relatively stable but the triage RN tells you her heart rate wasRead more

    • Otitis externa: use the ear wick!

      Acute otitis externa (AOE) is a common complaint seen in pediatric as well as adult emergency departments. AOE is typically not accompanied by acute otitis media, although concurrent cases are possible. Also called “swimmer’s ear”Read more